Department of Medicine, Mount Sinai Morningside and West, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
Division of Nephrology and Endocrinology, The University of Tokyo, Japan.
Int J Cardiol. 2024 Dec 15;417:132509. doi: 10.1016/j.ijcard.2024.132509. Epub 2024 Sep 4.
Evidence is lacking regarding the benefits of pulmonary artery catheter (PAC) for cardiogenic shock (CS).
We analyzed the data on Medicare fee-for-service beneficiaries aged 65-99 admitted with CS from 2016 to 2020 to compare outcomes of patients monitored with versus without PAC. We implemented propensity score matching weight (PSMW) analysis with hospital fixed effects (effectively comparing outcomes within the same hospital) and quasi-experimental instrumental variable (IV) analysis (accounting for potential unmeasured confounders) with the probability of using PAC for CS in the previous year as the instrument.
We included 4668 and 78,502 patients admitted with CS, monitored with and without PAC, respectively. We found no evidence that the use of PAC was associated with mortality either in PSMW (adjusted absolute risk difference [aRD], +0.5-percentage-points [pp]; 95 % confidence interval [CI], -1.1 to +2.1) or IV (aRD, -2.5 pp.; 95 % CI, -8.2 to +3.2) analyses. While consistent associations were not observed between the use of PAC and major bleeding and sepsis, the use of PAC was associated with a higher risk of all-bleeding (PSMW: aRD, +1.5 pp.; 95 % CI, +0.1 to +2.9; IV: +13.3 pp.; 95 % CI, +7.7 to +18.8) and longer LOS (PSMW: adjusted mean difference, +1.6 days; 95 % CI, +1.1 to +2.0; IV: +6.9 days; +4.9 to +9.0).
We found no evidence that the use of PAC was associated with lower mortality in patients with CS. While high-quality randomized trials are needed, providers should be careful about appropriate settings and indications of the use of PAC for the management of CS.
缺乏肺动脉导管（PAC）在治疗心源性休克（CS）方面的益处的证据。
我们分析了 2016 年至 2020 年 Medicare 按服务收费的 65-99 岁 CS 住院患者的数据，比较了使用和不使用 PAC 监测的患者的结局。我们实施了倾向评分匹配权重（PSMW）分析和准实验工具变量（IV）分析（考虑到前一年使用 PAC 的可能性作为工具），采用医院固定效应（实际上是在同一医院内比较结果）。
我们纳入了分别接受 CS 监测和未接受 PAC 监测的 4668 名和 78502 名患者。我们没有发现使用 PAC 与死亡率之间存在关联，无论是在 PSMW（调整后的绝对风险差异[aRD]，+0.5 个百分点[pp]；95%置信区间[CI]，-1.1 至+2.1）还是 IV 分析（aRD，-2.5 pp.；95% CI，-8.2 至+3.2）。虽然没有观察到 PAC 使用与大出血和脓毒症之间存在一致的关联，但 PAC 使用与全出血风险增加相关（PSMW：aRD，+1.5 pp.；95% CI，+0.1 至+2.9；IV：+13.3 pp.；95% CI，+7.7 至+18.8）和 LOS 延长（PSMW：调整平均差异，+1.6 天；95% CI，+1.1 至+2.0；IV：+6.9 天；+4.9 至+9.0）。
我们没有发现 PAC 使用与 CS 患者死亡率降低相关的证据。虽然需要高质量的随机试验，但提供者应谨慎对待 PAC 在 CS 管理中的适当应用场景和适应证。
